Hubert H. Humphrey Building
200 Independence Avenue
Washington, D.C.
DR. IEZZONI: What I thought we would do today is a couple of things. We have hopefully fairly brief, but very necessary agenda items, to figure out what you want to do about this table.
What I thought would be to just talk about the Medicaid managed care projects, because we, Marge and Elizabeth, were at HCFA all day yesterday, and we really put in a very long day. Well, we feel like we worked hard.
Unfortunately, Hortensia is not here today. However, we are under some time pressure about what exactly we want from the territories project. I think that there was a memorandum that I wrote back in October, I think, or late September, about this. It was a lengthy memorandum. It might have been scary because of its length, but a lot of it was, we want to do this briefly, we want to do this briefly.
Let's just be clear about what we are doing for the territories. We are getting about a day and a half meeting or two-day meeting.
(Simultaneous discussion.)
DR. ARAHI: Also, we invited Linda Wada to join us from Interior as well.
DR. IEZZONI: Oh, good, thank you.
DR. ARAHI: She is here to give us the lead agency's status on all of the insular areas, except Puerto Rico.
DR. IEZZONI: You are with the Department of --
DR. WADA: Interior.
DR. IEZZONI: Interior, okay. Let's all take a minute, and who would like to walk us through this?
DR. TUREH: Why don't I do it?
DR. IEZZONI: Okay, Joan.
DR. TUREH: We can rearrange, but what we did was, we set it up for you to have your introduction to kind of an overview. The charge, the way we structured it, was more related to what we found out is being done at this point. We asked Interior to start off with an overview of they do, because in the population data area, they have supported a very large program in data collection in the territories and freely associated states since 1990, and it would be interesting.
There have been some (word lost) censuses and household income and expenditure surveys, but we just need to understand what they have done. Some of their surveys have included health related questions such as disability. Since the Census Bureau has been their agent for working with the 1020 (word lost) surveys, --
DR. ARAHI: Plus they are working with the vital statisticians.
DR. TUREH: Right. Then we wanted to go from there to have you talk with our regions, who deal with Puerto Rico, the Virgin Islands and (word lost) to get an overview of what the department does.
Then there is a recent report in IOM which really talks about health issues in these areas, and so we wanted to hear about that. Then get a chance for our federal programmatic and data people to give you an overview of what we are doing within the department. We were going to also invite EPA to join us, and I will give you information on Social Security, Agriculture and Labor, because what they do is relatively small.
We thought most of the time should be focused on discussion of the data needs issue and perspective. There are eight insular areas that would need to make presentations, and we would give them a two-day meeting, basically to give them a lot of time to talk and interact.
DR. IEZZONI: Yes, that would be great.
DR. TUREH: Then after you have heard them all and had the dialogue, to have time to talk and come up with a recommendation. Then we are open to how you want to structure it. If we feel we've got too much time in one area or something --
DR. IEZZONI: Do you mean that representatives of these different insular areas will actually be at the meeting?
DR. TUREH: We have gotten monies from Olivia to bring in six people from the Pacific area.
DR. IEZZONI: Really?
DR. TUREH: And we were going to go to the House of Representatives of Puerto Rico and the Virgin Islands to try to get somebody to come through them, because we don't have enough money to pay their travel as well.
DR. HITCH: Yes, we've got a very active person from the Hill who staffs the Congressional liaison from Puerto Rico, who has been visiting the department, so we'll (word lost) him to talk about data needs.
DR. TUREH: And we were intending to send a letter of invitation to the heads of the health departments or the ministers of health and invite them to bring representatives who could talk about data. I guess it was HCFA who was scheduling a meeting in March --
DR. ARAHI: It is a combined NRSA-IOM meeting. From what I understand, HRSA -- so it would be the health officers who meet here. Your letter would be addressed to those individuals who are coming to this meeting here in Washington, D.C. the week of March 16.
DR. TUREH: We are going to invite them to send a representative, who was somebody who would be knowledgeable about data. We wanted to use this meeting as a way to get more of an open discussion of the kind of person who would be useful.
DR. IEZZONI: Given who you envision having come, and it will be very interesting to see their internal operation as well. So if you need --
DR. TUREH: Well, now, we didn't think that the heads of the department should come. We thought that they should get the invitation letter, so that --
DR. IEZZONI: To pick the representatives that you think are appropriate.
DR. TUREH: Yes, but we thought we needed to go through them so that the person who spoke would have some official status to speak on their areas.
DR. IEZZONI: What do you think about how this is arranged?
PARTICIPANT: My first reaction is that we only have an hour on that first day. I was wondering, Carolyn had done some magical things putting the panels together; I think we've got all the right people and entities here. Is there a way that you might sort this a different way to get panels that could interact more, rather than a lot of lectures?
PARTICIPANT: We had an opportunity to talk a little bit about it, and we want to just piddle with that and send it out to panels that are interactive with each other, so that it is not just Islander people or the (words lost) speaking to each other, but kind of mix the groups up so that there can be an interchange and they can hear each other. We can certainly work with that.
I think not only these are the right people, but you have done a super job in finding them. Thank you.
DR. IEZZONI: Well, thank you to you all, because this one has been a very difficult meeting, and it is much more political than a lot of them. Even compared to HCFA yesterday, I think this is probably a lot more (word lost) involved with it.
DR. WARD: I keep thinking what we was a committee are going to be likely to be able to do. Sort of like, what is the data, what is the value, so you can just -- I think we need to have the same sort of value. I have a sense that maybe the only thing that we are going to be able to do is to facilitate a broader communication. We will perhaps be better informed, but have them coming all the way from the Virgin Islands, so that I have a better understanding of the problem is not quite enough to make them come that distance.
DR. IEZZONI: That is why I said we want more interaction, we want more time for --
DR. WARD: Linda, you like look an important person here. Does that resonate at all in terms of -- you know these folks, you deal with them a lot. Is that going to be seen by them as helpful?
DR. WADA: The interaction?
DR. WARD: The interaction.
DR. WADA: From the Pacific, I don't think there is that interaction, not quite with the -- but the Virgin Islands, yes, with Puerto Rico, I would expect that the representatives would like a little bit more than just a didactic machine. But depending on who comes up from the Islands, some are maybe very comfortable and expect a lot of interaction. Others --
DR. WARD: Will there be a polite way of allowing them to feel comfortable and not put on the spot?
DR. WADA: I think part of it will be how we set up the panels. At lunch, we were talking at one point -- actually, Elizabeth and Carolyn and I just briefly talked about this. You want to mix the panels and not necessarily keep them this way. That would probably get to the where the committee has to be comfortable, what they really want to get out of it, in order for us to know what combinations to mix people up in.
DR. TUREH: I'm getting confused, because you are talking about very different kinds of data collection with these people. When you are talking about Interior, you are talking about population surveys from the databases, from (word lost) data. When you are talking about the regions, you are talking about health data from programs from the HHS which will in some cases be aggregate dollar values, we gave them a block grant of X dollars. When you are talking about Jill, you're talking about a very different kind of work as well with the IRN study, and then in each of the program areas, you are going to get things like -- except for NCHS and (word lost) where you're going to get some population-based data, you are going to be talking about, we collect data on how many people we have given school lunches to.
So I'm not sure what you're going to get when you match them. Part of it, I think we have taken a very broad data focus; what kind of data are we really interested in? We take a population survey; I am interested in major data (words lost), do we want to know how much money we spend on the training of (word lost) health. You're not going to be able to match them together in any way. Some are going to be based on people, some are going to be dollar aggregates, and so they won't have a lot to say to each other.
DR. RIMES: (Comments off mike.)
DR. ARAHI: But see, in this particular piece, it also would affect who we would ask to come.
DR. TUREH: I would like us to really focus on the first paragraph of the letter, do we have the right purposes.
DR. IEZZONI: That is what I was going to say. The letter has to say why it would be good for you to come, and what we would hope to get out of it.
DR. RIMES: Who would we recommend that they send, if we can do that?
DR. IEZZONI: The who I would leave up to you guys, because you know much better than I do. I think going back to the original discussion about having this meeting (words lost) interest of people like Bob Manderscheid from SAMHSA, who was talking about the dollars that SAMHSA gives in block grants for data to the Islands. The purpose of the meeting was to look at how (words lost) the kinds of programs that the federal government funds and other aspects of the health care delivery system, and to learn about where there are gaps, so we could recommend areas where data systems could be improved, with the implication being that if there is the need for data systems to improve, that maybe we should think about how to fund the improvement of those data systems.
Is that what people recall?
DR. WARD: Yes. I think what we kept hearing was is that we assume that the underlying problem is that there is not uniformity about who is asked for data, what kinds of data, so that these can affect those populations, for them to feel that they are uniformly capable of getting (word lost).
DR. TUREH: Yes, but that's the difference in health data. The problem in Puerto Rico was that to get certain kind of Medicaid children's benefit, you had to be able to pull three years of the CPS. The CPS doesn't collect data in Puerto Rico, it is not part of the sampling frame. So there was no data set available for their allocation. But that was not a health data system, but the current population --
DR. HITCHCOCK: It is a denominator system.
DR. TUREH: It is a denominator, yes. So a health data system which is, who do I give block grants to is going to say, I gave the Virgin Islands three million dollars. That is probably all it is going to tell you.
DR. IEZZONI: That is not what I meant. Person level health data.
DR. TUREH: Then you really want to concentrate on -- you need survey data, and then you need some things like innovation.
(Simultaneous discussion.)
DR. ARAHI: They have some kind of data. We don't know what the quality is.
DR. TUREH: A lot of the population based -- they can get health status, they will get health insurance coverage. They might ask HIS questions, number of doctor visits. They will get that kind of general information (words lost) immunized, and we have births and deaths.
DR. IEZZONI: (Comments off mike.)
PARTICIPANT: I don't know of any.
DR. IEZZONI: Well, for example, Medicare knows who all the (words lost) for a particular beneficiary and we thought we could link all those data to look at episodes of care or the health care for groups of beneficiaries.
DR. WADA: And I would say on specific use funding.
DR. ARAHI: Yes. It is mainly their medical records and their public health record of the Public Health Service, and their referral bank, which I guess ties back to Medicare.
DR. IEZZONI: How are doctors' office visits funded and how is health care paid for.
DR. WADA: Are you asking a general question?
DR. IEZZONI: Yes.
DR. WARD: And four of the six areas in health care assessment.
DR. IEZZONI: Fee for service and --
DR. ARAHI: No, it's like single payor. It is the government paid-for.
DR. IEZZONI: So the analogous thing would be the Balanced Budget Act requires the recording of encounters. You may not want to even think of recording of encounter data.
DR. ARAHI: Well, at one point I remember when I was out there, what they used to do is, for the categorical grants they had to report the encounters in order for them to qualify for the dollars. But with the block grants, I think that loosened their data requirements, so I don't really know what they are collecting now.
DR. TUREH: If they took three of these areas on freely associated states, which they are really separate countries?
DR. WADA: They are sovereignties.
DR. TUREH: And the ambassadorial relationship to us --
DR. WADA: And they (word lost)
in the UN.
DR. TUREH: The question is, they do get American dollars. The get block grants, I think.
DR. WADA: Yes.
DR. TUREH: Do we want them in or do you want them out?
DR. IEZZONI: I do not feel that they (words lost), do you guys?
DR. VAN AMBURG: I was going to say, I feel like we need a briefing on how the systems work over there.
DR. WADA: It is almost like we need --
DR. ARAHI: You're going to get this. This book is an IOM -- it did a needs assessment about what it is.
(Simultaneous discussion.)
DR. ARAHI: Because it does talk about (word lost), which I think is really interesting, and I think it has something about -- it talks about health services. For Virgin Islands it has health services. I think it has information that will give you some feel for them.
DR. IEZZONI: Well, for you who have spent much time with these folks, have you heard them talk about data that would help them, better knowledge on health care for their population?
DR. WADA: Absolutely.
DR. IEZZONI: That is what we need to hear. That is what we want to hear. We want to hear from them on what they need. We need to think about how to formulate recommendations.
DR. HITCHCOCK: That is what it says in the letter, and I think that is what we tried to say in the first paragraph in that letter.
(Simultaneous discussion.)
DR. ARAHI: If that is the case, then I think you are looking for the higher level, rather than the data mavens. We were the so-called data mavens.
DR. WADA: Statisticians or epidemiologists.
DR. ARAHI: Yes, because you want the people to have the broader --
DR. IEZZONI: (Comments off mike.) That is what we really want to do. We want to make this issue visible. We want to make visibility on this issue throughout --
DR. ARAHI: Visible to --
DR. IEZZONI: To the Secretary.
DR. ARAHI: To the Secretary and also to these other funding agencies, which heavily fund the --
DR. IEZZONI: Yes. Are these all HHS agencies?
DR. ARAHI: Some of them are. Is a secondary objective to get a dialogue going, a discussion going between the representatives for the insular areas as well as the feds? Initially, I thought that was what you were leaning towards.
DR. WARD: The few minutes we had at lunch, what we were trying to get from was just a whole day of people making verbal reports. I think I am learning now more about what would be appropriate and inappropriate in terms of facilitation, because I think there are some things one might have thought of that now sound very inappropriate.
DR. TUREH: The other thing is that you've got some really large size differences. Some of these are relatively small. They maybe have 10,000 people. In Puerto Rico you have probably very different data needs. One of the small areas, they radio in with some of these forms, but sometimes the radio doesn't work and they find out that person has been born when they start school. So you are talking about a very different kind of world for selecting and processing data.
DR. WARD: It sounds like we are trying to do bureaucratic language and needs assessment to find them all, and we're trying to find the best people to tell us. It seems to me it is the people themselves. After we hear from everybody, we can find out if they think there is a problem there. We could then decide what federal agencies we need to interact with.
DR. HITCHCOCK: Are you sure you want to do that? I would think to set the stage, you might want to hear very, very briefly -- that is what this would be -- very, very briefly about what the agencies think the most important programs are in those areas.
DR. TUREH: Well, we're spending money.
(Simultaneous discussion.)
DR. VAN AMBURG: You need to know what you're doing, as well as what they need.
DR. ARAHI: You do need to know the federal side of it, because that is where the funding source is. Even here, even these single agencies here, they (words lost).
DR. WADA: But there are so many planning types here, with the block grant or even some of the categorical grants. That is what comes out in this book, in terms of the data capacity, the different requirements. They need to fit into American style programs. In order to qualify for this funding, they have to still meet these requirements.
One thing that may come out of it is a recommendation about facilitating -- adapting these programs to the needs of these communities, do you know what I'm saying? Because that is one of the things that the insular area leaders have always said, that we need to have some kind of flexibility to make it work for us.
DR. TUREH: (Comments off mike.)
DR. HITCHCOCK: To go back to Elizabeth's point, I think we really need, Elizabeth, to have agency representatives here and have them play a short active role. We need to have them on the agenda so that they show up, so that we get somebody from the Islands that says, we are lacking this, and the person says we're planning to rectify that, or we do this program.
DR. WADA: If you are bringing (words lost) policy makers, they are sophisticated. They lobby up in Congress all the time.
(Simultaneous discussion.)
DR. WADA: -- a Rich Miller or someone from the office that works in the data area.
DR. TUREH: I think one important reason you have Interior is that they really are the only group that is giving money.
DR. WADA: No.
DR. TUREH: No? Who else?
PARTICIPANT: Giving money to what?
DR. TUREH: To the collection of data.
DR. ARAHI: No, these federal programs are, too.
(Simultaneous discussion.)
DR. ARAHI: That is why they also have an interest in trying to participate in the dialogue.
DR. WADA: Remember, I said Interior's data is very different. It is population. They are looking at denominators. It works with the Islands census people to do the 10 years and then do some special surveys. But essentially Interior has not really worked in the health area. We have health as a technical assistance program, but not data.
(Simultaneous discussion.)
DR. IEZZONI: It sounds like the immediate action item is that we need to feel comfortable about the letter. I think maybe reorganizing this paragraph a little bit to just emphasize our desire to assist as a highlight, and give more visibility to the needs that they have, would be good.
I think that it sounds like the folks around the table really know more than those on the committee side.
DR. VAN AMBURG: It's scary.
DR. IEZZONI: No, it isn't scary actually at all. It's the way that this particular meeting is working. So are there any other immediate actions or decisions that we need to make on them?
DR. WADA: (Comments off mike.)
DR. ARAHI: We didn't talk about that.
DR. WADA: (Comments off mike.
DR. ARAHI: I'll contact her.
DR. WADA: The HRSA summit runs from the 16th to -- I think it is the 19th and 18th of March. Then the health directors meet with the Institute of Medicine committee on the 19th and 20th on the national planning
DR. ARAHI: If she can't do it, --
DR. TUREH: I think it would be nice to have a letter to hand out there.
DR. IEZZONI: (Comments off mike.)
(Simultaneous discussion.
DR. ARAHI: The other thing that I think would be helpful to them, because if we are getting the policy makers (word lost) switching the letter of invitation, we need the questions that we feel the committee would like to hear. We need to be able to give it to them, because they will have the answers, so they will be prepared to discuss it, so that they won't be blindsided.
DR. WADA: You may not want the health ministers or health directors or the Secretary.
DR. HITCHCOCK: Is coming to Washington a big deal? If we had a chance to go out to the Islands --
DR. ARAHI: I think you know more, you interact with them a lot more, so you would have an idea of who to suggest.
DR. TUREH: I think we want them to tell us about population-based data, to the degree that it prevents them from coming up with incident rates.
DR. IEZZONI: Well, we want to hear from them what they feel that they need to know to manage health care.
DR. WADA: You are talking about informed decision making from their perspective, not from the federal perspective.
DR. IEZZONI: Although I think we are going to have to deal with the block grant issue
DR. ARAHI: I was kind of toying with the agenda, and I thought that -- one of the things that kind of went through my mind was, we could combine the panels and have the insular affairs, region two and nine together, and the IOM people up there as a panel, with the idea of giving the overview. Then I thought we could have the federal programs, just giving them a total of about 20 minutes. There's about two hours there. Then breaking for lunch and having the insular areas, having all eight of them discussing in the afternoon -- first go around of their perspective.
Then I thought the next day, they are laying their issues on the table and having the second go-round with the reaction from the feds, to think about, now that we have heard what the Islanders have said, are there some ways that we can maybe manage our program so that it can meet their data needs.
DR. TUREH: (Comments off mike.
DR. ARAHI: They also know some of the issues.
DR. WADA: But I don't think that would work unless you have --
(Simultaneous discussion.
DR. ARAHI: I was thinking have the Islanders, but maybe the second day have the dialogue. I don't know. I want to know ways to make this interaction.
DR. IEZZONI: Why don't we let you guys think about that, because it sounds like you know the specific people that you might want to -- why don't you get usa second draft of the letter, maybe again with what George said, which is what we hope to come out of this, which is specific recommendations.
DR. HITCHCOCK: That is in there, but you want to expand on it?
(Simultaneous discussion.)
DR. TUREH: I think the second half of that first paragraph we can rewrite. I think we've got a lot of stuff we don't need. I don't think we need to worry about privacy and confidentiality. I think we want to understand what kind of health data do they need in order to better manage their health care system, or better manage health care for their populations.
DR. RIMES: Some of what I think George was talking about, and what we've done in the past, we usually write the questions. Some of the questions may help identify what it is that we want. I think when it all comes together, it usually comes together like that, the letter, the questions, who is on the committee, because they always want to know that, what the work plan is for the committee, things like that.
PARTICIPANT: But I think we do a very general statement in the letter, and then the questions get more specific? We can sure work on that.
DR. IEZZONI: You'll get another draft to me.
PARTICIPANT: I'll call Hortensia to find out about her availability.
DR. IEZZONI: George?
DR. VAN AMBURG: I would like to see a draft letter that is going to the funding agency
DR. ARAHI: I was going to ask, should the questions also be the same? It should be a little different, shouldn't it?
DR. VAN AMBURG: It should be different.
DR. IEZZONI: Just to warn you, I'm going to take vacation, so if you need this letter finalized --
(Simultaneous discussion.
DR. ARAHI: You need it by Friday?
DR. IEZZONI: Yes, I would need to see it by Friday
DR. ARAHI: Actually, you need it by Friday so you can sign it.
DR. RIMES: How about Thursday
DR. ARAHI: Well, because the meeting is the 16th, and you want to pretty much hand deliver it to them.
DR. IEZZONI: So I feel slightly uncomfortable that Hortensia hasn't been able to have specific input into this.
DR. RIMES: Yes, I know. I think we can remedy that with a package.
DR. IEZZONI: I think that -- Richard, do you have anything? Okay.
(Simultaneous discussion.
DR. ARAHI: There was only one problem with the dates, and I don't know if the census guy will be able to change.
DR. TUREH: He won't be here. The 15th and 16th, the gentleman who is working on the collection wont' be here. He'll be in Egypt or someplace. But Interior will be here and all of these efforts are sponsored by Interior
DR. ARAHI: And the federal people who were at the meeting that we had actually marked the dates. The federal people at the meeting that we had actually kept those dates on their calendars.
DR. IEZZONI: I really want to thank everybody. It has been a marvelous job.
DR. TUREH: Can I ask one other question? What we are going to do is (words lost) the letter to say that we are interested in talking with them about their needs for population-based data.
DR. IEZZONI: Well, no, I wouldn't say population-based, because that is such a trendy term. I would just say data to help manage the health care of their population. Then they will tell us what they want or what they feel that they need and where the gaps are to them and what the hurdles are for them. In an area that only has 14,000 residents, or the one that radios in whether a child is born, --
(Simultaneous discussion.)
DR. HITCHCOCK: On George's point about the recommendations, if we could just characterize what kinds of recommendations we need.
DR. VAN AMBURG: Well, you don't want to characterize recommendations, but you've got to get the feeling that it is going to be worth their while to do this. It is a long way, and it is going to be productive, and we are going to do something with the information that they give us. I didn't get that feeling about of this letter. Come over and tell us stuff, and we'll see if anything happens.
DR. IEZZONI: Tell people who know nothing about you, which is kind of what we are asking. So I think that we need to be clear that the national committee does have a (words lost) here, having the committee function and bringing visibility to issues.
DR. VAN AMBURG: Would it be appropriate to send a copy of some previous reports or recommendations to the Secretary as examples of --
DR. ARAHI: Sure, we can give you a copy of annual report.
(Simultaneous discussion.)
DR. WARD: It sounds like also this report, so that we are not asking them to give us the same information that they have already provided --
DR. IEZZONI: I talked to the woman who did the (words lost).
(Simultaneous discussion.)
DR. IEZZONI: Great. So is everything settled around the table?
DR. WARD: I just have one question. Do you think as you heard us formulating what we are doing and why we are doing this, does this seem worth --
DR. WADA: I can tell you that the Virgin Islands and the Pacific Islands, the jurisdictions, have been after HHS for many years to help them with data infrastructure development, not crunching numbers, but the real infrastructure.
DR. WARD: So there is an area up there, if we can mobilize ourselves with the Data Council and the Secretary to say you need to pay more attention to this area. It is such an enormous amount of travel time.
(Simultaneous discussion.)
DR. ARAHI: -- that Interior does nothing with Puerto Rico, so none of the data collections that have been sponsored relate to Puerto Rico. I think we probably know less about what is going on there right now.
DR. IEZZONI: And we need to have Puerto Rico at the table
DR. ARAHI: Puerto Rico will be at the table. That same letter is going to go Puerto Rico.
DR. IEZZONI: Great, good, Elizabeth, that was an excellent question. Thank you.
(Simultaneous discussion.)
DR. IEZZONI: We just finished, Jim, our discussion on the Islands and territories, and it was actually very, very productive. Elizabeth asked the key question about whether what we were doing might be valuable for them. The answer was yes. So I just warn you, in your position with the Data Council, that the recommendations that we will be making will be coming to you. So it was very, very productive.
(Simultaneous discussion.)
PARTICIPANT: Is the agenda more or less -- you can move it around, obviously, but --
DR. IEZZONI: It is so impressive that you are going to be able to bring in people from the Islands.
(Simultaneous discussion.)
DR. IEZZONI: But keep in mind that one of the recommendations might be to buy a generator for the Islands.
DR. RIMES: I think that has come up several times.
(Simultaneous discussion.)
PARTICIPANT: The Federated States of Micronesia was the only other country that voted with the United States when we didn't sanction Israel. I can't remember what the issue was, but it was the United States --
DR. IEZZONI: For the last half hour, to talk about where we are headed in Medicaid managed care initiative. Paul, maybe what I could do is talk to you at some point about what we have been doing with that, so we don't take up time here, and catch you up to date.
But Carolyn, Mary and Jason, what do you have for us?
DR. RIMES: Well, what we have done, Mary has an outline (words lost). Jason is doing yeoman work and has put together under topics some of the things, office amendments and some of the site visits. I think it is a terrific first beginning. Like every other thing we touch on this, it could cut a variety of different ways.
DR. IEZZONI: Do we have a copy of this?
DR. RIMES: You will be.
DR. RIMES: (Comments off mike.)
DR. GOLDWATER: Essentially, what I did was go back over every transcript of every meeting that you have had since July.
DR. IEZZONI: We had three in Washington and had two days in Boston.
DR. GOLDWATER: Right. What I did initially was go down and basically take every -- what I thought was relevant point from every meeting that you had, and about 18 pages later I realized that the document was probably a little too long to be handing out. I started to cut from there. When I had something that I thought was presentable, I showed it to Carolyn, who looked at it and made a number of suggestions to tie it down even further, until we got to the document that I (word lost).
I think the first thing that I noticed that I'm sure you all noticed is, there are a number of issues, probably more issues than could possibly be covered in our report. That is my opinion, and I think that is a tribute to the speakers that we have had, who have covered the whole wide range of topics and a host of issues. There has been a lot of talk about dual eligibles on mental health and substance abuse, a lot of data integration, on dissemination and collection, analysis, infrastructure development. The talks about Arizona were themselves quite revealing, about not only the things that we went over, but added of course new dimensions.
So I found six topic areas that I thought most of the things would fall under. I'm sure some of them have fallen through. I somewhat condensed those 18 pages into some substantive issues to be looked at.
DR. IEZZONI: Then Mary, you tell us what you have done. Have you been working with Jason (words lost)?
DR. MOEIR: I would say (word lost) because the first I had seen of this -- what I had done was, basically I came on board with the Phoenix meeting, and then Kathy Coltin -- we had discussion at the Phoenix meeting the idea for the report, and I jotted down some ideas that everybody had given at that time, and I had gotten her notes, also, in terms of that she was jotting down what other people were saying, too. I put together the one-page outline.
I will tell you, it was based a lot on the discussions in Phoenix and then the subsequent talks there, because it really was after I did this that I had a chance to start going back -- I hadn't been to any of the earlier meetings, so it was really after I did that that I went back and started reading, and then the other day actually picked up the information on the other contract which is going to be rolled in, too, which has to do with the data issue with the other contract.
As it ends up related, it was not addressed here at all, except that it does relate to the idea of data items to be collected. Also, after I had written it, I heard back from Carolyn, but I really did go through, looking at the ideas that were discussed in Phoenix and just the general overall thoughts that I thought would be coming up in terms of -- because I came up with five key areas, some of which I think may already be parts of Jason's. But the key questions we need to answer regarding the Medicaid population, at the individual aggregate level, and then I just had some thoughts on data, and what data items need to be collected, what are the experiences of states currently collecting data, what were the uses of the data, and then data dissemination. Those were some of the areas that I had come up with.
Carolyn had gotten back to me and said that she really liked the documented overview section, that some more background information about Medicaid, welfare reform. So I really did just kind of jump into topics, but I haven't read what Jason has pulled together, either.
DR. IEZZONI: I recall the discussion at HEMA. I felt very comfortable with how we were coming, which is reflected in the way that you thought this through. I think that you and Jason were in fact doing somewhat different things. So I like Mary's -- the way that she patterned (words lost).
DR. WARD: My first reaction was how remarkably similar they are.
DR. GOLDWATER: That's why I left the meeting yesterday, was to finish this and make it somewhat --
DR. RIMES: (Comments off mike.)
DR. MOEIR: The one area you had mentioned that you liked a certain style, and I didn't know if you had a chance to bring anything from GAO before us.
DR. IEZZONI: I didn't, but I do know the titles and I can bring them to you. But the basic point is, we don't want a long report. It has to be very thin. So I appreciate Jason going through what is probably (words lost) and distilling that. We are going to need to distill out any further than what we have done here.
But let me just get a sense. George, I see you scribbling.
DR. VAN AMBURG: I would be careful about making the report so succinct. You have all the state Medicaid directors who will be using this report, state legislators and what have you as well, so there has to be enough substance behind it to make it worthwhile. I think the structure is similar to the reports the committee has done, of putting a very good executive summary, where the key recommendations are right up front and the substance behind it works very, very well.
DR. IEZZONI: Oh, yes, I agree with that.
DR. RIMES: That is what we have been talking about, with other things addended on.
DR. IEZZONI: We are going to have to figure out how to integrate that. We probably want a report addenda in some fashion, but we are also going to need to integrate everything. Can you just remind us exactly what the deliverables are? I thought they were supposed to report to us on the current state of data reporting requirements, as well as to give us proposals for our language.
(Simultaneous discussion.
DR. ARAHI: What they wanted to do was meet with us and have a conversation about what states -- they were supposed to talk to a few people in the states. They wanted us to give them an idea of which states they thought they really needed to talk to, in addition to the --
DR. HITCHCOCK: They were going to do a legal landscape of what it looked like out there.
DR. RIMES: Yes, and I don't have it, but it is due in March.
PARTICIPANT: I don't have it with me, either, but I know it is March.
DR. IEZZONI: Well, if there is something that we need to do for them. They haven't called anybody or told us that
DR. ARAHI: Actually, they told me. That was on my list to ask you all, to see which states we feel they need to -- there are six states that they were trying to look at. Or nine states? I think it was nine. But anyway, that is one of the things that they wanted from us.
DR. IEZZONI: I'm going to have to go around --
(Simultaneous discussion.)
DR. IEZZONI: Do you know anything about any states especially having an interest in --
DR. WARD: But they know enough about what they are doing that we could use them as models.
(Simultaneous discussion.)
DR. GOLDWATER: Iowa has the best encounter data.
DR. WARD: Yes, Richard. What we are really trying to find are states that have figured out some of the answers, or think they have figured out, so we can recommend to others, don't waste millions of dollars making mistakes other people have already learned from.
(Simultaneous discussion.)
DR. IEZZONI: Can we get this clarified? Because we don't want the contractors saying they can't do the work.
DR. VAN AMBURG: We'll give them a list of states, and if they recommend some substitutions based on their experience, that's fine
DR. ARAHI: Well, they have, place costs in nine Medicaid -- I've got their work plan -- place costs in nine Medicaid agencies according to the agreed-upon criteria, (word lost) Medicaid managed care contract database, begin to review instruments.
DR. IEZZONI: Well, clarify a little bit whether we have to participate further in (words lost).
DR. VAN AMBURG: Are all the states doing (words lost), because we ought to have some that are and some that are not.
DR. RIMES: I think we're going to be more apt to talk about the criteria selection.
DR. WARD: Certainly I think the criteria we have mentioned is success, different sizes and variation of experiments and the carveout issues, particularly the mental health and alcohol carveouts, on how those Medicaid agencies work with their state and mental health agencies.
DR. IEZZONI: Carolyn, you were speaking earlier about the need to do assessment reports. How would assessment reports be integrated into the document?
DR. RIMES: (Comments off mike.)
DR. IEZZONI: I feel that we don't have the ability to (words lost), because we just need to read it through and digest it. We haven't had a chance here to do that. So what I want to figure out is, what should be the process for our subcommittee to help manage (words lost) the folks who are going to be helping us prepare this document over the next four months or so as the document is being planned. We don't have another full committee meeting until June. We have the April hearings in Boston, but given what it sounds like the regional office is going to be planning for us, we are going to be busy the whole two days with hearing what happened in Massachusetts.
DR. MOEIR: Are we anticipating it is going to be a similar type of meeting?
DR. IEZZONI: I think there will be more (word lost) schedule.
(Simultaneous discussion.
DR. ARAHI: Since we had the (word lost) with Sam and his staff, he has pulled back the amount of staff support that he can give us, because they are being overextended. They are preparing a bicentennial.
DR. IEZZONI: Oh, are we doing a bicentennial
DR. ARAHI: No, they are, we're not doing it, they are doing it.
(Simultaneous discussion.
DR. ARAHI: That is the week before. But that is why he was trying to pull back in terms of amount of staff work. So he has provided -- they have provided a list of people we can contact. We sort of negotiated --
DR. IEZZONI: Well, we need to start doing this. Do we have a meeting room?
DR. ARAHI: We have a meeting room. All that is done.
DR. IEZZONI: Where are we going to be meeting
DR. ARAHI: In the John F. Kennedy Federal Building.
(Simultaneous discussion.
DR. ARAHI: No, we have the meeting room, we have the hotels.
DR. VAN AMBURG: Hotels
DR. ARAHI: Well, there are two choices. One is the Parker House and the other one is the Marriott.
DR. IEZZONI: The Marriott Longworth?
(Simultaneous discussion.
DR. ARAHI: But anyway, they are all within walking distance.
DR. IEZZONI: The Longworth Marriott is walking through the big dig, Tip O'Neill's present to Massachusetts. That is where they are tearing up all the roadways.
(Simultaneous discussion.)
DR. IEZZONI: What time are we going to get started? I think we should get started at 9:30. I think 9:30, because Sam was talking about people driving from the western part of the state. So I think we should try and start at 9:30.
(Simultaneous discussion.)
DR. IEZZONI: But the question still stands, how should we be interacting with staff around preparation of this report, given that we have so little time together between now and June? So much is preliminary writing and pulling it together.
DR. WARD: It's like they have a choice of everyone on the committee reviewing a different comment. We can circulate the drafts to you to comment.
(Simultaneous discussion.)
DR. IEZZONI: Okay, we want comments on this by Friday.
DR. GOLDWATER: If the group can agree on a fairly detailed outline, that is often the best way to proceed.
DR. IEZZONI: That is what I think we need to see, Jason and Carolyn interacting around an outline that comes from the transcripts
DR. ARAHI: Yes, because the Sara Rosenbaum report needs a separate standing contract.
(Simultaneous discussion.)
DR. RIMES: There will be analysis and recommendations on the report.
DR. VAN AMBURG: Yes, there will be blocks included
DR. ARAHI: We asked for that as one of the deliverables?
DR. RIMES: Yes, we did.
DR. MOEIR: I would say though, as Jason was talking about, as you look through -- at least, in terms of what I would like to see, if you look in some areas and think, I don't even want to think about going in this direction, it is just going to be opening up a can of worms that we can't address or something. So if you have some areas that you think are too broad or another time or something, I'd be interested in knowing that, too.
DR. IEZZONI: Well, there is going to be an interesting staff function that we should probably talk about, and that is, what do you do when you get inconsistent recommendations. For example, if George is really interested in the dual eligibles and --
(Simultaneous discussion.)
DR. VAN AMBURG: I would be comfortable if that occurs, if we take all the information and synthesize it and make some recommendations.
DR. IEZZONI: Well, just so long as it is fed back to us.
DR. RIMES: A second round
DR. ARAHI: But anyway, that final report though, we are not targeting until September, anyway.
DR. IEZZONI: That's right, but I think that it is going to take a lot more, and I would really recommend that you get started on the writing of a detailed outline, because we had the major kind of hearings, we're not going to be getting --
DR. RIMES: You're saying, we do know the issues.
DR. IEZZONI: We know the issues. All we don't know yet is what Sara's (words lost) which is very focused, and hopefully it will be very well written, and so hopefully it will be integrated very easily. Yes, it probably will be.
PARTICIPANT: And on the HCFA website you have descriptions of the waiver states already, and on the Kaiser Family Commission website they have a tremendous amount of information.
DR. RIMES: There is also that thing I told them, whatever it is, that survey they have done on changes in the community.
PARTICIPANT: Robert Wood Johnson, is that the one? Oh, Kaiser?
DR. RIMES: No, it is another place. The other source that I can't remember at the moment. It pulls things together for Arizona perhaps as well, and anything on how the community comes together.
DR. IEZZONI: So I would recommend -- Mary, is your time -- are you available?
DR. MOEIR: Yes. I had planned on doing something by June, to have something done at the June meeting.
DR. IEZZONI: Well, I think we need an outline.
DR. MOEIR: Okay. Yes, I need to do a lot of work looking through this. I guess I would like to see from you all, especially since -- I need to see the GAO reports you are interested in.
(Simultaneous discussion.)
DR. MOEIR: But you really indicated how you were interested in --
DR. IEZZONI: (Comments off mike.)
DR. MOEIR: Well, but I wasn't there for any of those, because you all hired me after that. So I would really be interested in knowing if you had specific people that you really thought --
(Simultaneous discussion.)
DR. MOEIR: The Phoenix people I kind of know, and I could see how you all felt. So if you had specific people that you thought really made great presentations, then those I would try to go back and actually look at the transcripts on.
DR. IEZZONI: How are people feeling? This is a big job, and we need to know that (words lost) people for these recommendations. So I feel that having just a breakout at the June meeting -- is that going to be adequate for us to begin to start thinking about recommendations?
DR. VAN AMBURG: If you have a draft set of recommendations to work with, you could probably do it.
DR. IEZZONI: And we don't have any (word lost) scheduled until September
DR. ARAHI: You've got the July meeting.
(Simultaneous discussion.)
DR. MOEIR: Are we meeting Tuesday and Wednesday
DR. ARAHI: It is the 14th and 15th.
DR. IEZZONI: I think that for recommendations we have to be fresh. Meeting at the end of the day --
(Simultaneous discussion.)
DR. IEZZONI: Can you poll the committee and see if they would be willing to stay through to 11:00 on the day after? If you let me know soon, I can arrange for --
DR. ARAHI: Do you want me to do that?
DR. IEZZONI: I would appreciate it
DR. ARAHI: I will poll certain about a half a day meeting on Wednesday, the 16th.
DR. WARD: Thursday
DR. ARAHI: You're right, Thursday, April 16.
(Simultaneous discussion.)
DR. IEZZONI: Kathy Coltin I think would be good
DR. ARAHI: I'll include Kathy Coltin on that.
DR. GOLDWATER: A small suggestion. I think that for those who live in Massachusetts, if you have recommendations for people you want to see on the panel -- Sam has given us some people, but certainly not enough to at this point -- I know a couple of people I think would be good, from my experience.
DR. IEZZONI: We should have Kathy. Kathy is the best person I know.
(Simultaneous discussion.)
DR. VAN AMBURG: She would want to hear from the perspectives of the providers, the state agencies and patient advocacy.
DR. RIMES: Kathy is e-mail. There is never enough opportunity for conversation.
DR. IEZZONI: Yes, although she will probably be here tomorrow. And maybe somebody from (word lost) organization. Are we done? There should be some briefing materials, kind of the analogous thing to the Arizona meeting, where we got a little bit of information about Medicaid and managed care. Wasn't it Boston that was one of the cities where there is a center for --
(Simultaneous discussion.
DR. ARAHI: I have already polled them. I am actually going to them for some contacts.
DR. IEZZONI: Are there other things that we want to say? I have one question, Donna, I can't believe I'm actually going to ask it. Do we want any kind of follow-up from the (word lost) or do we want to leave that dormant?
DR. RIMES: We really don't need any additional trauma.
DR. IEZZONI: I kind of meant what I said facetiously this morning. I think Congress has handed us an impossible task. I think that our committee can actually run some blockage for you on that, and that HCFA may come to us.
(Simultaneous discussion.)
DR. IEZZONI: But the point is that I will be talking about this tomorrow when we talk about our subcommittee reports, and we do need to think forward to the Medicaid managed care (words lost) I think that we should be thinking about this whole other area in the next big thing that we tackle. I think that it cuts across so many different populations, the home health and people with disabilities and people with long-term care needs and frail elderly and so on.
DR. RIMES: I think at this point that we are not going to plan on any additional --
DR. IEZZONI: I think that was information gathering. It gave me actually -- it was a great meeting.
DR. RIMES: I learned a lot.
DR. IEZZONI: Yes, it was great.
(Simultaneous discussion.)
DR. RIMES: We usually do a thank you letter anyway.
DR. IEZZONI: Let's have a letter, have it just come from me.
(Simultaneous discussion.)
DR. RIMES: I talked to him. Actually, he was more upset about some of the conversation behind him. It was endless, and hard to present. So I talked to him afterwards, and I will thank him. Well, you saw me intervene. He was very uncomfortable.
DR. IEZZONI: It was a very politically charged day, but it was extremely productive.
(Simultaneous discussion.)
DR. IEZZONI: The next one I'm going to say tomorrow, that our next big initiative after the Medicaid managed care would be looking at this whole thing that progress is forcing us to look at a new word for. We'll come up with another word for it, but it basically spans the gamut of a lot of acute care hospitals and not doctors' offices, everything else.
DR. RIMES: All I could think of when we were talking about definitions yesterday was, we could call it aftercare.
(Simultaneous discussion.)
DR. IEZZONI: Can we adjourn early? We are officially adjourned. Thank you.
(Whereupon, the meeting was adjourned at 5:10 p.m.)